Antibiotic Prescribing Guidelines October 2014

Antibiotic Prescribing Guidelines October 2014
ANTIBIOTIC PRESCRIBING GUIDELINES

FOR COMMUNITY ACQUIRED INFECTIONS IN GENERAL PRACTICE
Document Description
Document Type
Service Application
Version
Ratification date
Review date
Operational Guidance
Primary Care
7
March 2015
December 2015
Name
Noel Aslett
Lead Author(s)
Position within the Organisation
Prescribing Adviser Office of Public Health
Change History
Version
1
2
3
4
5
6
7
Date
March
2006
March
2008
Oct 2008
April 2009
September
2009
September
2010
October
2014
Link with Standards for

Better Health Domains
Comments
Original version by Anne Noott
Updated version
Updated version
Updated nitrofurantoin advice for uncomplicated UTI
Annual review
Annual Review no change
Annual Review no change other than hyperlinks
C4 and D1 safety
D2 clinical and cost effectiveness
SUMMARY SHEET
These guidelines have been reviewed and updated to take into account the
need for prudent antibiotic use in the face of healthcare associated infections,
principally Clostridium difficile and MRSA.
They aim to promote the safe, effective and economic use of antibiotics and to
minimise the emergence of bacterial resistance in the community.
Recommendations for prescribing are based on the guidelines produced by the
Dudley Group of Hospitals NHS Trust and in consultation with clinicians from
both primary and secondary care in Dudley.
These guidelines are for use by all staff employed or contracted by Dudley
CCG when treating patients in a primary care setting (e.g. GP surgery).
Produced in consultation with:

N Aslett
Prescribing Adviser, Office of Public

Health, Dudley MBC
Prescribing Lead, SWL locality
Antimicrobial Pharmacist, DGoH
Prescribing Lead, SGC locality
GP, CCG Clinical Lead, Prescribing
Specialist in Pharmaceutical Public
Health, Office of Public Health, Dudley
MBC
Prescribing Lead, HQB locality
Prescribing Lead, DN locality
Prescribing Lead, KAB locality
Consultant Microbiologist, DGoH
Dr S Berwick
M Biggs
Dr R Bramble
Dr PD Gupta
Dr D Jenkins
Dr H Khan
Dr D Shukla
Dr A Skilbeck
Dr E Rees
The guidelines will be subject to annual review or sooner depending on

changes in national guidance.
Contents
Summary
Contents
Introduction
Aims
Principles of treatment
Audit
Summary of Antibiotic Prescribing Guidelines:
- quick reference for use in practice
Antibiotic Prescribing Guidelines in depth
Upper respiratory tract infections
Lower respiratory tract infections
Urinary tract infections
Gastro-intestinal infections
Skin/soft tissue infections
References
Pg No
2
3
4
7
8
9
10
11
12
Introduction
Aims
to provide a simple, best guess approach to the treatment of common
infections
to promote the safe, effective and economic use of antibiotics
to minimise the emergence of bacterial resistance in the community
Principles of Treatment
1. This guidance is based on the best available evidence but its
application must be modified by professional judgment.
2. A dose and duration of treatment is suggested. In severe or recurrent
cases consider a larger dose or longer course
3. Prescribe an antibiotic only when there is likely to be a clear clinical
benefit.
4. Consider a no, or delayed, antibiotic strategy for acute sore throat,
common cold, acute cough and acute sinusitis.
5. Limit prescribing over the telephone to exceptional cases.
6. Use simple generic antibiotics if possible. Avoid broad spectrum
antibiotics (e.g. co-amoxicillin, quinolones and cephalosporins)
when narrow spectrum antibiotics remain effective, as they
increase risk of Clostridium difficile, MRSA and resistant UTIs.
7. Avoid widespread use of topical antibiotics (especially those agents also
available as systemic preparations).
8. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high
dose metronidazole. Short-term use of trimethoprim (theoretical risk in
first trimester in patients with poor diet, as folate antagonist) or
nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely
to cause problems to the foetus.
9. We recommend clarithromycin as it has less side-effects than
erythromycin, greater compliance as twice rather than four times daily &
generic tablets are similar cost. In children erythromycin may be
preferable as clarithromycin syrup is twice the cost.
Where a best guess therapy has failed or special circumstances exist,
microbiological advice can be obtained from 01384 244056
Audit
Adherence to the guidelines will be audited on a minimum annual basis.
Summary of antibiotic prescribing guidelines

The table below and overleaf provides summarised information for treatment choice in
common infections.
For further information on the basis of the choice and other clinically relevant information
please refer to the guidelines in depth.
Please note when prescribing doxycycline that the patient should be counselled to
avoid ingesting anything high in Ca, Fe, Mg and Zn salts within two hours of
doxycycline dose doing so could lead to reduced absorption and therefore treatment
failure.
Macrolide antibiotics interact with many medications [see drug specific product
characteristics (SPC) for full list and latest BNF note statin therapy should be
suspended when treating with clarithromycin]
Condition
Pharyngitis /
sore throat /
tonsillitis
Otitis media
(child doses)
Acute sinusitis
Acute cough /
bronchitis
Communityacquired
pneumonia
Acute
exacerbation of
COPD
Uncomplicated
UTI
First Line
Phenoxymethylpenicillin
500mg QDS
Alternative(s) / Allergy
If allergy:
Clarithromycin 500mg BD
Amoxicillin 40mg/kg/day
in 3 divided doses Max 1g
TDS
If allergy:
Clarithromycin
<8kg
7.5mg/kg BD
8-11kg 62.5mg BD
12-19kg 125mg BD
20-29kg 187.5mg BD
30-40kg 250mg BD
12-18 years 250-500mg BD
Second Line:
Co-amoxiclav
1-6 yrs 5ml of 125/31 susp TDS
6-12 yrs 5ml of 250/62 susp TDS
250mg QDS or 500mg BD
Doxycycline 200mg
stat/100mg OD
Doxycycline 200mg
stat/100mg OD
Doxycycline 200mg
stat/100mg OD
AND
500mg QDS
Doxycycline 200mg
stat/100mg OD
Nitrofurantoin
100mg modified release
(MR)capsules BD
(Unless eGFR less than
45ml/min/1.73m2)*
(Note: local resistance of
25% to trimethoprim)
Duration
10 days
5 days
5 days
7 days
5 days
Only if penicillin allergic or

doxycycline contraindicated:
(monotherapy) see page 8
If doxycycline contraindicated:
Trimethoprim
200mg BD if organism susceptible
Up to
10 days
5 days
3 days;
diabetics
and
7 days
(If sending for MC&S use RED

top bottle only)
2
* can be used in patients with eGFR 30-45 ml/min/1.73m with suspected or proven multidrug resistant
pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects.
Summary of antibiotic prescribing guidelines (continued)

Condition
UTI in
pregnancy
Acute
pyelonephritis
Recurrent UTI
in women
3 per year
Clostridium
difficile
Also see CCG
policy on C diff
infection
First Line
1st and 2nd trimester
nitrofurantoin*
50mg QDS
Co-amoxiclav 625mg
TDS
Prophylactic
nitrofurantoin 50mg at
night
Metronidazole 400mg
TDS
(avoid suspension
questionable effect in
diarrhoea disperse
tablets in water if unable
to swallow whole)
Cellulitis
(if water
exposure d/w
microbiologist)
Flucloxacillin 500mg
QDS
Animal / Human
bite
Co-amoxiclav
625mg TDS
Impetigo
(reserve topical
for very
localised
lesions)
Flucloxacillin 500mg
QDS
Fusidic acid topically QDS
Alternative(s) / Allergy
2nd and 3rd trimester trimethoprim
200mg BD
If penicillin allergic:
Trimethoprim 200mg BD
Prophylactic Trimethoprim
100mg at night
Add Vancomycin 125mg QDS if
pt not responding at 5 days
If responding on combination
complete 14 day course at same
time (i.e. 14 days metronidazole
and 9 days vancomycin)
If penicillin allergy:
If MRSA positive:
Doxycycline 200mg stat then
100mg OD
If allergy:
Metronidazole 400mg TDS and
doxycycline 100mg BD
Mupirocin topically QDS
(Reserve for MRSA)
Duration
7 days
14 days
14 days
7-14 days
7 days
7 days
5 days
Antibiotic Prescribing Guidelines - in depth

COMMENTS
DRUG
DOSE
ILLNESS
UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antibiotic prescriptions.
Influenza
Pharyngitis /
sore throat /
tonsillitis
Otitis media
(child doses)
A-
Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults antivirals not
recommended. Treat at risk patients, when influenza is circulating in the community and within 48 hours of onset
or in a care home where influenza is likely. At risk: pregnant (including up to two weeks post partum), 65 years or
over, chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not
hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease. Use 5 days
treatment with oseltamivir 75 mg bd unless pregnant or if there is resistance to oseltamivir, use 5 days zanamivir 10
mg BD (2 inhalations by diskhaler) and seek advice. For prophylaxis, see NICE. (NICE Influenza). Patients under
13 years see HPA Influenza link.
The majority of sore throats are viral; most patients do not benefit from antibiotics. Consider a delayed
antibiotic strategy and explain soreness will take about 8 days to resolve. Patients with 3 of 4 centor criteria (history
of fever, purulent tonsils, cervical adenopathy, absence of cough) or history of otitis media may benefit more from
AA+
antibiotics. Antibiotics only shorten duration of symptoms by 8 hours. You need to treat 30 children or 145 adults
A+
to prevent one case of otitis media.
Evidence indicates that penicillin for 7 days
B+
is more effective than 3 days. Twice
Adaily higher dose can also be used. QDS
D
may be more appropriate if severe.
First line
phenoxymethylpenicillin
500 mg QDS
10 days
clarithromycin
if allergic to penicillin
500 mg BD
10 days
Many are viral. Illness resolves over 4

A+
days in 80% without antibiotics.
First line
amoxicillin
40mg/kg/day in 3
divided doses
Maximum 1g TDS
5 days*
if allergic to penicillin
clarithromycin
<8kg 7.5mg/kg BD
5 days*
Use NSAID or paracetamol.
Need to treat 20 children >2y and seven 624m old to get pain relief in one at 2-7
A+B+
days.
20-29kg 187.5mg BD
Children with otorrhoea, or <2years with

bilateral acute otitis media, have greater
benefit but are still eligible for delayed
prescribing.
Haemophilus is an extracellular pathogen,
thus macrolides, which concentrate
intracellularly, are less effective treatment.
Many are viral. Symptomatic benefit of

antibiotics is small - 69% resolve in 7-10
days without antibiotics; and 84% resolve
A+
B+
with antibiotics. Reserve for severe or
symptoms (>10 days).
Cochrane review concludes that amoxicillin
and phenoxymethylpenicillin have similar
efficacy to the other recommended
antibiotics.
If failure to respond use another first line
antibiotic then second line
8-11kg 62.5mg BD
12-19kg 125mg BD
Antibiotics do not reduce pain in first 24

A+
hours, subsequent attacks or deafness.
Acute sinusitis
DURATION
OF TX
30-40kg 250mg BD
12-18 years 250500mg BD
Second line
co-amoxiclav
doxycycline
OR
1-6 yrs 5ml of 125/31

suspension TDS
6-12 yrs 5 ml of
250/62 suspension
TDS
5 days*
200 mg stat/100 mg
OD
7 days
250 mg QDS/500mg
BD
7 days
Second line:
clarithromycin
500mg BD
7 days
If Recurrent infection:
co-amoxiclav
625 mg TDS
7 days
A+
-Note interaction with Ca,

Fe, Mg and Zn. Please
advise patient to avoid
ingesting anything high in
these salts within 2 hours
of doxycycline doses
* Standing Medical Advisory Committee guidelines suggest 3 days. In otitis media, relapse rate is slightly higher at 10 days with a 3
A+.
day course but long-term outcomes are similar.

COMMENTS
DRUG
DOSE
ILLNESS
DURATION
OF TX
LOWER RESPIRATORY TRACT INFECTIONS

Note: Avoid tetracyclines in pregnancy. Low doses of penicillins are more likely to select out resistance. The quinolones ciprofloxacin
and ofloxacin have poor activity against pneumococci. However, they do have use in PROVEN pseudomonal infections. Levofloxacin
has some anti-Gram-positive activity but should not be needed as first line treatment.
Acute cough,
bronchitis
Acute
exacerbation
of COPD
NICE
In primary care, antibiotics have marginal

A+
benefits in otherwise healthy adults.
B+
Patient leaflets can reduce antibiotic use.
doxycycline
30% viral, 30-50% bacterial, rest

undetermined
First line:
doxycycline
- Note interaction with
Ca, Fe, Mg and Zn.
Please advise patient to
avoid ingesting anything
high in these salts within
2 hours of doxycycline
doses
Use clarithromycin
(if doxycycline
contraindicated)
Use antibiotics if increased dyspnoea and

B+
increased purulence of sputum volume.
Use clarithromycin if doxycycline
contraindicated
If clinical failure to first line antibiotics refer
to sputum microbiology results or seek
advice from consultant microbiologist
Communityacquired
pneumonia (CAP)
treatment in
the
community
BTS
Start antibiotics immediately.
B-
200 mg stat/100 mg
OD
5 days
200 mg stat/100 mg
OD
5 days
500 mg BD
5 days

Ca, Fe, Mg and Zn.
doses
If no response in 48 hours consider admission.

C
In severely ill give parenteral benzylpenicillin before admission and seek risk factors for Legionella and Staph.
D
aureus infection.
Assess CRB-65 score 1 point for each of
the following
Confusion-recent
Respiratory rate 30 breaths/min or more
Blood pressure systolic < 90mmHg,
diastolic 60mm Hg
Age 65 years
If score 3 admit to hospital urgently
Score 2 arrange same day assessment in
secondary care
Score 0 or 1 home treatment may be
appropriate depending on clinical
judgement and social support
*Please note:
On local microbiology advice the
combination of doxycycline and
phenoxymethylpenicillin is the preferred
option.
The use of clarithromycin is limited to
those with an allergy or contraindication as
its routine use in CAP is less effective than
st
the preferred 1 line choice.
First line:
doxycycline
AND
200 mg stat/100 mg
OD
Up to 10 days
500mg QDS
Up to 10 days
500mg BD
Up to 10 days

Ca, Fe, Mg and Zn.
doses
Alternative:
*Only if penicillin allergic
or doxycycline
contraindicated:
Clarithromycin
(monotherapy)

COMMENTS
ILLNESS
URINARY TRACT INFECTIONS
DRUG
DOSE
DURATION
OF TX
Note: Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (>65 years), do not treat
B+
asymptomatic bacteriuria; it occurs in 25% women and 10% of men and is not associated with increased morbidity. In the
presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelonephritis likely.
Uncomplicated
UTI i.e. no
fever or flank
pain in
men & women
nitrofurantoin
(Unless eGFR less than
2
45ml/min/1.73m )*
Community multi-resistant E. coli with

Extended-spectrum Beta-lactamase
enzymes (ESBLs) are increasing so
perform culture in all treatment failures.
or
All urine samples which require MC&S

please use RED top bottle
UTI in
pregnancy
Children
Acute
pyelonephritis
A-
Use urine dipstick to exclude UTI -ve

nitrite and leucocyte 95% negative
predictive value.
Send MSU for culture. Short-term use of

trimethoprim or nitrofurantoin in pregnancy
is unlikely to cause problems to the
B+
foetus.
st
nd
*1 and 2 trimester nitrofurantoin
nd
rd
*2 and 3 trimester trimethoprim
Refer children <3 months to specialist.
Send MSU in all for culture &
susceptibility. If 3 years, use positive
nitrite to start antibiotics. Refer children
post UTI for imaging.
Send MSU for culture.

If no response within 24 hours admit.
100mg modified
release (MR) BD
B+
3 days
(7 days in
diabetics and
men)
B+
trimethoprim (note:
200 mg BD
local resistance of >25%
so recommend urine for
MC&S first)
Second line: depends on susceptibility of organism isolated ESBLs
are multi-resistant but often remain sensitive to nitrofurantoin
2
* can be used in patients with eGFR 30-45 ml/min/1.73m with
suspected or proven multidrug resistant pathogens when the
benefits of nitrofurantoin are considered to outweigh the risks of
side effects.
nitrofurantoin
or
trimethoprim
depending on semester*
100mg modified
release (MR) BD
7 days
7 days
200 mg BD
Second line depending

on microbiology
sensitivities
nitrofurantoin
or
trimethoprim
See BNF for Children

for dosage
Lower UTI
3 days
500/125 mg TDS
14 days
trimethoprim
200 mg BD
14 days
Prophylactic
nitrofurantoin
50 mg
OD at night
co-amoxiclav
If co-amoxiclav not
suitable i.e. allergy to
penicillins then use
Recurrent UTI
women 3/yr
Nightly prophylaxis. As low compliance,

consider standby antibiotic.
OR
trimethoprim
100 mg
COMMENTS
DRUG
DOSE
ILLNESS
DURATION
OF TX
GASTRO-INTESTINAL TRACT INFECTIONS

Infectious
diarrhoea
Antibiotic therapy not indicated unless patient systemically unwell or post-antibiotic, suggesting
Clostridium difficile.
Clostridium
difficile
Stop unnecessary antibiotics and/or PPIs

to re-establish normal flora.
70% respond to metronidazole in 5 days;
94% in 14 days.
Severe if T >38.5; WCC >15, rising
creatinine or signs/symptoms of severe
colitis.
See Dudley Formulary site for detailed
guidance on Clostridium difficile
management
st
1 line
metronidazole
Please avoid
metronidazole
suspension as
questionable
effectiveness in
diarrhoea. If patient
cannot swallow
metronidazole tablets
whole, it is better to
disperse them in water
prior to administration.
nd
2 line
Vancomycin
(if switching from
metronidazole due to
ineffectiveness, STOP
metronidazole)
Travellers
diarrhoea
400mg oral TDS

be sure to review
treatment at 72 hours
to ensure the patient is
responding. Refer to
gastrology if markers
of severe disease with
significant systemic
symptoms or not
systemically unwell
consider switching
nd
therapy to 2 line
10-14 days
125mg oral QDS

If responding to
treatment complete
course.
If still not responding
following switch to
vancomycin or
evidence of severe
infection seek advice
from consultant
microbiologist
10 -14 days*
Limit prescription of antibacterial to be carried abroad and taken if illness develops (ciprofloxacin 750 mg single
dose) to people travelling to remote areas and for people in whom an episode of infective diarrhoea could be
dangerous.
In areas of high ciprofloxacin resistance (Asia) can advise prophylactic bismuth subsalicylate (Pepto Bismol) 2
tablets QDS.
10

COMMENTS
DRUG
DOSE
ILLNESS
DURATION
OF TX
SKIN/SOFT TISSUE INFECTIONS for MRSA screening or treatment see MRSA Prevention and Control Policy
Panton-Valentine Leukocidin (PVL) is a toxin produced by 4.9% of S. aureus from boils/abscesses. This bacteria can rarely cause
severe invasive infections in healthy people; if found suppression therapy should be given1C. Send swabs if recurrent
boils/abscesses. At risk: close contact in communities or sport; poor hygiene 1C
Impetigo
Eczema
Cellulitis
flucloxacillin
First Oral 500 mg QDS
7 days
Systemic review indicates topical and oral
A+
OR clarithromycin
line Oral 500 mg BD
7 days
treatment produces similar results.
As resistance is increasing reserve topical
Topically QDS
5 days
C or D
antibiotics for very localised lesions
mupirocin
Topically QDS
5 days
Reserve Mupirocin for MRSA.
Using antibiotics, or adding them to steroids, in eczema encourages resistance and does not improve healing
unless there are visible signs of infection. In infected eczema, use treatment as in impetigo.
If patient afebrile and healthy other than
cellulitis flucloxacillin may be used as
single drug treatment. If water exposure,
discuss with microbiologist.
If febrile and ill, admit for IV treatment
flucloxacillin
500 mg QDS
7 14 days
clarithromycin
500 mg BD
7 14 days
200 mg stat/100mg od
7 14 days
If positive for MRSA use:

doxycycline
A+
Leg ulcers
Animal bite
Human bite
Bacteria will always be present. Antibiotics do not improve healing. Culture swabs and antibiotics are only
indicated if there is evidence of clinical cellulitis; increased pain; enlarging ulcer or pyrexia. Need to debride any
slough before commencing antibiotic treatment to ensure most intervention is most effective.
Review antibiotics after culture results.
flucloxacillin
500 mg QDS
7 days
Refer for specialist opinion if severe
infection.
Surgical toilet most important.
Assess tetanus and rabies risk.
Antibiotic prophylaxis advised for
puncture wound; bite involving hand, foot,
face, joint, tendon, ligament;
immunocompromised, diabetics, elderly,
asplenic
First line animal & human
Antibiotic prophylaxis advised.
metronidazole PLUS
Assess HIV/hepatitis B & C risk
doxycycline
prophylaxis and
treatment
B-
co-amoxiclav
625 mg TDS
7 days
400 mg TDS
7 days
100 mg BD
7 days
Note interaction with Ca,

Fe, Mg and Zn. Please
advise patient to avoid
ingesting anything high in
these salts within 2 hours
of tetracycline doses
Conjunctivitis
Most bacterial infections are selfA+

limiting (64% resolve on placebo ). They
are usually unilateral with yellow-white
mucopurulent discharge.
Fusidic acid has less Gram-negative
activity
chloramphenicol
0.5% drops PLUS
1% ointment
fusidic acid
11
2 hrly reducing to QDS

at night
1% gel BD
All for 48 hours

after resolution
Clostridium difficile infection Treatment algorithm
12
13
14
15
16
References
Management of Infection Guidance for Primary Care for Consultation and Local
Adaptation October 2014 Public Health England,
http://www.gov.uk/government/publications/managing-common-infectionsguidance-for -primary-care
This guidance was initially developed in 1999 by practitioners in South Devon, as part of
the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing
Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS
Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the
Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified
following comments from Internet users. The guidance has been updated annually as
significant research papers, systematic reviews and guidance have been published.
The Health Protection Agency works closely with the authors of the Clinical Knowledge
Summaries.
Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.
Study design
Recommendation
grade
Good recent systematic review of studies
A+
One or more rigorous studies, not combined
A-
One or more prospective studies
B+
One or more retrospective studies
B-
Formal combination of expert opinion
Informal opinion, other information
Clinical Knowledge Summaries web http://www.prodigy.nhs.uk. BNF (No 55), SMAC report The path of least resistance (1998), SDHCT Medical Directorate guidelines + GU medicine
guidelines, Plymouth Management of Infection Guidelines project LRTI and URTI.
UPPER RESPIRATORY TRACT INFECTIONS
Influenza
Algorithm for prescribing oseltamivir or zanamivir for treatment of influenza-like illness
(Updated Feb 2005)
http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1191942171468
th
(Accessed 5 June 2008)
Oseltamir for influenza. Drug & Therapeutic Bulletin 2002;40:89-91. (Review of benefits of
oseltamir in influenza)
Turner D, Wailoo A, Nicholson K et al. Systematic review and economic decision modelling for
the prevention and treatment of influenza A and B. University of Leicester 2002.
17

Pharyngitis/sore throat/tonsillitis
Centor RM, Whitherspoon JM Dalton HP, Brody CE, Link K. The diagnosis of strep throat in
adults in the emergency room. Med Decision Making 1981;1:239-46. Scoring system for sore
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Del Mar C & Glasziou P. Antibiotics for the symptoms and complications of sore throat. In: The
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Index Medicus 1945-65. Medline 1966 to 1997; Cochrane Library 1997 Issue 4; hand search of
reference lists of relevant articles.
Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database
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(Accessed 5th June 2008)
Del Mar C. Sore throats and antibiotics: Applying evidence on small effects is hard; variations
are probably inevitable. Brit Med J 2000;320:130-1. Editorial covering treatment.
Del Mar C & Glasziou P. Sore Throat. In: Clinical Evidence Concise. London. BMJ Publishing
Group. 2006;15:516-17
Lan AJ, Colford JM, Colford JMJ. The impact of dosing frequency on the efficacy of 10 day
penicillin or amoxicillin therapy for streptococcal tonsillopharyngitis: A meta-analysis. Pediatr
2000;105(2):E19. Meta-analysis showed BD and QDS dose equivalent.
Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL. Open randomised trial of
prescribing strategies in managing sore throat. BMJ 1997;314:722-7. RCT showing that
antibiotics only marginally effect resolution of symptoms but enhance belief in antibiotics and
intention to consult in the future compared to no antibiotic or delayed antibiotic.
McIsaac WJ, Goel V, Slaughter PM, Parsons GW, Woolnough KV, Weir PT, Ennet JR.
Reconsidering sore throats. Part 2: Alternative approach and practical office tool. Can Fam
Physician 1997;43:495-500. Review of scoring system that supports Centor.Clinical
Knowledge Summary @
th
http://www.prodigy.nhs.uk/search?&page=1&q=acute%20sore%20throat&site=0 (Accessed 5
June 2008)
Zwart Sjoerd, Sachs APE, Ruijs G, Gubbels JW, Hoes AW, de Melker RA. Penicillin for acute
sore throat: randomised double blind trial of seven days versus three days treatment or
placebo in adults. Brit Med J 2000;320:150-4. RCT showing 7 days penicillin V at 500 mg
was better than 3 days in terms of time of symptom resolution, bacterial resolution and relapse.
Also confirms validity of Centor criteria.
Scottish Intercollegiate Guidelines Network. Management of sore throat and indications for
tonsillectomy. 1999. http://www.sign.ac.uk/guidelines/fulltext/34/index.html (Accessed 5th June
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Otitis media
Dagan R, Klugman KP, Craig WA. Baquero F. Evidence to support the rationale that bacterial
eradication in respiratory tract infection is an important aim of antimicrobial therapy. J
Antimicrob Chemother 2001;47:129-140. (Discusses penetration of antibiotics in OM)
Damoiseaux RAMJ, Van Balen FAM, Hoes AW, de Melker RA. Antibiotic treatment of acute
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1998;48:1861-4.
18

Damoiseaux RAMJ, Van Balen FAM, Hoes AW, Verhiej TJM, de Melker RA. Primary carebased randomised, double blind trial of amoxicillin versus placebo for acute otitis media in
children aged under 2 years. Brit Med J 2000;320:350-4.
Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with
acute otitis media? A meta-analysis. Brit Med J 1997;314:1526-9. Search date 1966 to
August 1994; primary sources Medline, current contents.
Froom J, Culpepper L, Jacobs M, de Melker RA, Green LA, Van Buchem L, Grob P, Heeren T.
Antimicrobials for acute otitis media? A review from the International Primary Care Network.
Brit M J 1997;315:98-102.
Glasziou IP, Del Mar CB, Sanders SC, Hayem M. Antibiotics for acute otitis media in children
(Cochrane Review). In: The Cochrane Library 2006. Issue 4. Chichester, UK: John Wiley &
Sons, Ltd 8 studies (4 primary care)
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(Accessed 31 January 2008)
Kozyrskj AL, Hildes Ristein E, Longstaffe SEA, Wincott JL, Sitar DS, Klassen TP et al.
Treatment of acute otitis media with a shortened course of antibiotics: a meta-analysis. JAMA
1998;279:1736-42.
Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomised
controlled trial of two prescribing strategies for childhood acute otitis media. BMJ
2001;322:336-42.
Little P. Gould C, Moore M, Warner G, Dunleavey J. Williamson I. Predictors of poor outcome
and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial.
BMJ 2002;325:22-26.
ONeill P & Roberts T. Acute otitis media in children. In: Clinical Evidence. London. BMJ
Publishing Group 2006 Jun;(15):500-10
Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA, Gaboury I,
Little P, Hoes AW. Antibiotics for acute otitis media: a meta-analysis with individual patient
data. Lancet 2006;368:1429-35. Shows that patients with otorrhoea, or children <2 years with
bilateral acute otitis media benefited more from antibiotics (NNT 3 and 4 respectively).
Acute sinusitis
de Ferranti SD, Lonnidis JPA, Lau J, Anniger WV, Barza M. Are amoxicillin and folate
inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis. Brit Med J
1998;317:632-7. Search date May 1998; primary sources Medline 1966 May 1998; manual
search of Excerpta Medica: recent abstracts for Interscience Conference on Antimicrobial
Agents & Chemotherapy 1993-1997 and references of all trails review articles and special
issues for additional studies.
Kim AS. Sinusitis (acute). In: Clinical Evidence Concise. London BMJ Publishing Group
2006;15:215-17
Diagnosis and treatment of acute bacterial rhinosinusitis. Summary, Evidence
Report/Technology Assessment: Number 9 March 1999. Agency for Health Care Policy &
Research, Rockville MD. http://www.ahcpr.gov/clinic/sinussum.htm
Hansen JG, Schmidt H, Grinsted P. Randomised, double blind, placebo controlled trial of
Penicillin V in the treatment of acute maxillary sinusitis in adults in general practice. Scan J
Prim Health Care 2000;18:44-47.
19

International Rhinosinusitis Advisory Board. Infectious rhinosinusitis in adults. Classification,
aetiology and management. Ear Nose & Throat Journal 1997;76 (12 Suppl):1-22.
Clinical Knowledge Summary @ http://www.cks.library.nhs.uk/search?&page=1&q=sinusitis&site=0
th
(Accessed 5 June 2008)
Williams Jr JW, Aguilar C, Cornell J, Chiquette E. Dolor RJ, Makela M, Holleman DR, Simel DL.
Antibiotics for acute maxillary sinusitis (Cochrane Methodology Review). In: The Cochrane Library, Issue
4, 2003. Chichester, UK: John Wiley & Sons, Ltd.
http://www.antibioticresistance.org.uk/ARFAQs.nsf/0/44BFE0C0107D0CC380256F350045B0F4?OpenDo
st
cument (Accessed 31 January 2008) 3 RCTs; 375 adults.
LOWER RESPIRATORY TRACT INFECTIONS
Woodhead M, Blasi F, Ewig S, Huchon G, Leven M, Ortqvist A, Schabert T, Torres A, can der
Jeijden G, Werheij TJM. Guidelines for the management of adult lower respiratory tract
infection. Eur Respir J 2005;26:1138-80. Appendices 1 and 3 give detailed methods and
definitions, with rationale for antibiotic dosage recommendations.
st
http://www.erj.ersjournals.com/contents-by-date.0.shtml (Accessed 31 January 2008)
Acute bronchitis
Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. In: The Cochrane Library,
2006, Issue 4. Chichester, UK: John Wiley & Sons, Ltd
(Accessed 7th May 2008). Systematic review of nine studies (4 in primary care). Studies in primary
care showed antibiotics reduced symptoms of cough and feeling ill by less than one day in an illness
lasting several weeks in total.
Fahey T, Stocks N, Thomas T. Quantitative systematic review of randomised controlled trials
comparing antibiotic with placebo for acute cough in adults. Brit Med J 1998;316:906-10.
Wark P. Bronchitis (acute). In: Clinical Evidence. London. BMJ Publishing Group.
2006;15:1996-2005
Macfarlane J, Holmes W, Gard P, Thornhill D. Macfarlane R. Reducing antibiotic use for acute
bronchitis in primary care: blinded, randomised controlled trail of patient information leaflet.
BMJ 2002;324:91-4.
Treatment of cough available in Clinical Knowledge Summaries website:
http://www.cks.library.nhs.uk/search?&page=1&q=sore%20throat%20acute&site=0 (Accessed
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7 May 2008)
COPD
Anthonisen MD, Manfreda J, Warren CPW, Hershfield ES, Harding GKM, Nelson NA.
Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Int Med
1987;106:196-204.
Calverley PMA, Walker P. Chronic obstructive pulmonary disease. Lancet 2003;362:1053-61.
Excellent review on pathophysiology and management of COPD. Little detailed information on
antibiotic treatment.
20

Chronic obstructive pulmonary disease. Management of COPD in adults in primary and
secondary care. NICE Clinical Guideline 12 February 2004.
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http://www.nice.org.uk/CG012NICEguideline (Accessed 7 May 2008)
Community-acquired pneumonia
BTS guidelines for the management of community-acquired pneumonia in adults. Thorax
2001;56(Suppl 4):IV1-64.
Hopstaken RM, Muris JWM, Knottnerus JA, Kester ADM, Rinkens PELM, Dinant GJ.
Contributions of symptoms, signs, enthrocyte sedimentation rate and C-reactive protein to a
diagnosis of pneumonia in acute lower respiratory tract infection. Brit J Gen Pract 2003;53:358364.
Loeb M. Community-acquired pneumonia. In: Clinical Evidence. London BMJ Publishing
Group. 2006;15:2015-24.
URINARY TRACT INFECTIONS
Elderly
Abrutyn E, Mossey J, Berlin JA, Boscia J, Levison M, Pitsakis P, Kaye D. Does asymptomatic
bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly
ambulatory women? Ann Int Med 1994:827-33.
Nicholl LE. Urinary tract infection. In: Infection Management for Geriatrics in Long-term Care
Facilities. Eds Yoshikawa TT, Ouslander JG. Marcel Dekker. New York. 2002:173-95.
Uncomplicated UTI
Barclay L. New guidelines for management of urinary tract infection in nonpregnant women. Medscape
Medical News. http://www.medscape.com/viewarticle/571545?src=rss (Accessed 25th April 2008)
Charlton CAC, Crowther A, Davies JG, Dynes J, Howard MWA, Mann PG, Rye S. Three day
and ten day chemotherapy for urinary tract infections in general practice. Brit Med J
1976;1:124-6.
Christiaens TCM, Meyere M De, Vershcraegen G. Peersman W, Heytens S. Maeseneer JM
De. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of
uncomplicated urinary tract infection in adult women. Brit J Gen Pract 2002;52:729-34.
Davey PG, Steinke D. MacDonald TM, Phillips G, Sullivien F. Not so simple cystitis: How
should prescribers be supported to make informed decisions about the increasing prevalence
of infections caused by drug resistant bacteria? Brit J Gen Pract 2000;50:143-46.
Dobbs FF & Fleming DM. A simple scoring system for evaluating symptoms, history and urine
dipstick testing in the diagnosis of urinary tract infections. J Roy Col Gen Pract 1987;37:100-4.
Ellis R & Moseley DJ. A comparison of amoxicillin, co-trimoxazole, nitrofurantoin,
macrocrystals and trimethoprim in the treatment of lower urinary tract infections. Management
of UTIs. Ed. LH Harrison. 1990. Royal Society of Medicine Services International Congress &
Symposium Series No. 154, publishers RSM Services Ltd. pp 45-52.
21

Gossius G Vorland L. The treatment of acute dysuria-frequency syndrome in adult women:
double blind randomized comparison of three day versus ten day trimethoprim therapy. Curr
Ther Res 1985;37(1):34-42.
Guay DR. An update on the role of nitrofurans in the management of urinary tract infections.
Drugs 2000;61:353-64.
Hiscoke C, Yoxall H, Greig D, Lightfoot NF. Validation of a method for the rapid diagnosis of
urinary tract infection suitable for use in general practice. Brit J Gen Pract 1990;40:403-5.
Hummers-Pradier E. Kocken MM. Urinary tract infections in adult general practice patients. Brit
J Gen Pract 2002;52:752-61.
Livermore D, & Woodford N. Laboratory detection of bacteria with extended-spectrum betalactamases. CDR Weekly
2004;14 No. 27.
McCarty JM, Richard G, Huck W, Tucker RM, Toxiello RL, Shan M, Heyd A, Echols RM. A
randomised trial of short-course ciprofloxacin, ofloxacin or trimethoprim/sulfamethoxazole for
the treatment of acute urinary tract infection in women. Am J Med 1999;106:292-9.
MeReC Bulletin. UTI. August 1995.
Spencer RC, Moseley DJ, Greensmith MJ. Nitrofurantoin modified release versus trimethoprim
or co-trimoxazole in the treatment of uncomplicated urinary tract infection in general practice. J
Antimicrob Chemother 1994;33(Suppl A):121-9.
UTI in pregnancy
Information from the National Teratology Information Service (Tel: 0191 230 2036, Fax: 0191
232 7692) states:
Trimethoprim is a folate antagonist. In some women low folate levels have been associated
with an increased risk of malformations. However, in women with normal folate status, who
are well nourished, therapeutic use of trimethoprim for a short period is unlikely to induce folate
deficiency.
A number of retrospective reviews and case reports indicate that there is no increased risk of
foetal toxicity following exposure to nitrofurantoin during pregnancy. Serious adverse reactions
eg peripheral neuropathy, severe hepatic damage and pulmonary fibrosis are extremely rare.
Nitrofurantoin can cause haemolysis in patients with G6PD deficiency. Foetal erythrocytes
have little reduced glutathione and there is a theoretical possibility that haemolysis may occur.
However, haemolytic disease of the new-born has not been reported following in utero
exposure to nitrofurantoin.
Children
Larcombe J. Urinary tract infections in children. In: Clinical Evidence Concise. London. BMJ
Publishing Group 2007 December pp 125-8.
National collaborating centre for womens and childrens health. Clinical guideline. Urinary tract
infection in children. Diagnosis, treatment and long-term management.
st
http://www.nice.org.uk/nicemedia/pdf/CG54fullguideline.pdf Accessed 31 January 2008)
Comprehensive guidance with summaries and flow charts.
Acute pyelonephritis
22

Talan DA, Stamm WE, Hooton TM, Moran GJ, Burke T, Iravani A, Reuning-Scherer J and
Church DA. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14
days) for acute uncomplicated pyelonephritis in women. A randomized trial. JAMA
2000;283:1583-90. Evidence for 7 days ciprofloxacin and 14 days trimethoprimsulfamethoxazole if susceptible.
Warren JW, Abrutyn E. Hebel JR et al Guidelines for antimicrobial treatment of uncomplicated
bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis 1999;29:745-58.
Recurrent UTI in non-pregnant women

Albert X, Huertas I, Pereir I, Sanflix J, Gosalbes V, Perrota C. Antibiotics for preventing
recurrent urinary tract infection in non-pregnant women. Cochrane Database of Systematic
Reviews 2004, Issue 3, Art No. CD001209. DOI: 10.1002/14651858.CD001209.pub2. This is
an excellent review of prophylaxis. It shows that it is very effective (NNT2). However 30% do
not comply. Benefit lost as soon as prophylaxis stops and prophylaxis after intercourse is as
effective as daily prophylaxis.
GASTRO-INTESTINAL TRACT INFECTIONS

Clostridium difficile
Belmares J, Gerding DN, Parada JP, Miskevics S, Weaver F, Johnson S. Outcome of
metronidazole therapy for Clostridium difficile disease and correlation with a scoring system. J
Infect 2007;55:495-501. Of 83% of patients who dont respond to 5 days metronidazole, 30%
do respond by 14 days.
Gastroenteritis
de Bruyn G. Diarrhoea in adults (acute). In: Clinical Evidence. London. BMJ Publishing Group
2006;15:1031-48. Summarises evidence for a single dose or 3 days of ciprofloxacin in
treatment of travellers diarrhoea.
Farthing M, Feldman R, Finch R, Fox R, Leen C, Mandal B, Moss P, Nathwani D, Nye F,
Percival A, Read R, Ritchie L, Todd WT, Wood M. J of Infect 1996;33:143-52. The
management of infective gastroenteritis in adults. A consensus statement by an expert panel
convened by the British Society for the Study of Infection.
Clinical Knowledge Summaries: Gastroenteritis
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http://www.prodigy.nhs.uk/search?&page=1&q=gastroenteritis&site=0 (Accessed 7 May
2008)
Goodman LJ, Trenholme GM, Kaplan RL el al. Empiric antimicrobial therapy of domestically
acquired acute diarrhoea in urban adults. Arch Intern Med 1990;150:541-6.
Travellers diarrhoea
What to do about Travellers diarrhoea. Drugs & Therapeutic Bulletin 2002;40:36-38.
Spira AM. Travel Medicine 1: Preparing the traveller. Lancet 2003;361:1368-81. Summarises
treatment of travellers diarrhoea in a simple table.
Centres for Disease Control and Prevention Travellers Health: Yellow Book.
http://wwwn.cdc.gov/travel/yellowBookCh4-Diarrhea.aspx. (Accessed 14.04.08). Gives
details of bismuth subsalicylate.
23
Dupont HL. Systematic review: prevention of travellers diarrhoea. Aliment Pharmacol Ther
2008;27:741-51.
SKIN/SOFT TISSUE INFECTIONS

Impetigo
George A, Rubin G. A systematic review and meta-analysis of treatments for impetigo. Brit J
Gen Pract 2003;53:480-87. (No difference between topical mupirocin and fusidic acid, no
significant difference between topical and oral).
Livermore D. James D, Duckworth G, Stephens P. Fusidic acid use and resistance. Lancet
2002;360:806.
MeReC Bulletin. Acne. November 1994.
Mupirocin and fusidic acid resistance increasing in Staphylococcus aureus. N Zealand Public
Health Report 1999;6:53.
Shanson DC. Clinical relevance of resistance to fusidic acid in Staphylococcus aureus. J
Antimicrob Chemother 1990;25(Suppl B):15-21.
Sladden MJ, Johnston GA. Common skin infections in children. BMJ 2004;329:95-99.
Waite DG, Collins PO, Rowsell B. Topical antibiotics in the treatment of superficial skin
infections in general practice a comparison of mupirocin with sodium fusidate. J Infect
1989;18:221-9.
Wilkinson JD. Fusidic acid in dermatology. Brit J Dermatol 1998;139:37-40.
Eczema
Smethurst D & Macfarlane S. Atopic eczema. In: Clinical Evidence. London. BMJ Publishing
Group. Available on web only by subscription
http://www.clinicalevidence.com/ceweb/conditions/cvd/1716/1716_background.jsp ( Accessed
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7 May 2008)
Hoare C, Li Wan PA, Williams H (2000). Systematic review of treatments for atopic eczema.
Health Technology Assessment 2000;4(37):1-191.
Clinical Knowledge Summaries: atopic eczema.
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http://www.prodigy.nhs.uk/search?&page=1&q=atopic%20eczema&site=0 (Accessed 7 May
2008)
Cellulitis
Dilemmas when managing cellulitis. Drugs & Therapeutic Bulletin 2003;41:43-46. (Review of
the management of cellulitis)
Eron LJ, Lipsky BA, Low DE, Nathwani D, TiceAD, Volturo GA. Managing skin and soft tissue
infections: expert panel recommendations on key decision points. J Antimicrob Chemother
2003;52 (Suppl S1):i3-17.
24
Diabetic leg ulcer

Jeffcoate WJ, Harding KG. Review: Diabetic foot ulcers. Lancet 2003;361:1545-51.
Animal/human bites
Anderson CR. Animal bites. Guidelines to current management. Postgraduate Medicine
1992;92:134-49.
Goldstein EJC. Bites. In: Mandell GL, Bennett JE, Dolin R Eds. Principles and Practice of
Infectious Diseases. Churchill Livingstone. 2000;2:3202-05.
Jones DA & Standbridge TN. A clinical trial using co-trimoxazole in an attempt to reduce
wound infection rates in dog bite wounds. Postgraduate Medical J 1985;61:593-4.
Medeiros I, Saconat H. Antibiotic prophylaxis for mammalian bites (Cochrane Review). In: The
Cochrane Library, 2006 Issue 4. Chichester. John Wiley & Sons Ltd.
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(Accessed 7 May 2008)
Clinical Knowledge Summaries: bites.
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http://www.prodigy.nhs.uk/search?&page=1&q=bites%20human&site=0 (Accessed 7 May
2008)
Snook R. Dog bites man. Brit Med J 1982:284-93.
Wiggins ME, Akelman E, Weiss A-PC. The management of dog bites and dog bite infections to
the hand. Orthopaedics 1994;17:617-23.
Conjunctivitis
Epling J & Smucny J Bacterial conjunctivitis. In: Clinical Evidence Concise. London. BMJ
Publishing Group. 2006;15:234-5
Rose PW, Harnden A, Brueggemann A, Perera R, Skeikh A, Crook D, Mant D.
Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a
randomised double-blind placebo-controlled trial. Lancet 2005;366:37-43.
25

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